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    <title>死亡医学证明书</title>
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        /* 表单区域 */
        .form-container {
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        .form-section {
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            /* padding-bottom: 25px; */
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        .section-title {
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        .form-row {
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        .form-group {
            padding: 0 10px;
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        .form-group-full {
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        /* 新的三列表格样式 */
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        .disease-table td {
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        .disease-table tr:last-child td {
            border-bottom: none;
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        .disease-table .disease-label {
            font-weight: 500;
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        }
        
        .disease-table input {
            width: 100%;
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            border-radius: 4px;
            font-size: 14px;
        }
        
        .disease-table input:focus {
            outline: none;
            border-color: #1a6fc4;
            box-shadow: 0 0 0 2px rgba(26, 111, 196, 0.2);
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        .signature-box {
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            min-width: 280px;
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        .signature-title {
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        .signature-line {
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            margin: 40px 0;
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        .signature-line::after {
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        @media print {
            body, html {
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            .container {
                width: 210mm;
                height: 297mm;
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            .actions, .footer {
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    </style>
</head>
<body>
    <div class="container">
        <div class="header">
            <h1>居民死亡医学证明（推断）书</h1>
        </div>
        
        <div class="actions">
            <button class="action-btn print-btn" onclick="printForm()">
                <i class="fas fa-print"></i> 打印并预览
            </button>
            <button class="action-btn reset-btn" onclick="resetForm()">
                <i class="fas fa-redo-alt"></i> 重置表单
            </button>
        </div>
        
        <div class="form-container">
            <!-- 省市区信息 -->
            <div class="form-section print-page">
                <h3 class="section-title">行政区信息</h3>
                <div class="form-row">
                    <div class="form-group">
                        <label class="form-label">省（自治区、直辖市）</label>
                        <input type="text" class="form-input" id="province">
                    </div>
                    <div class="form-group">
                        <label class="form-label">市（地区、州、盟）</label>
                        <input type="text" class="form-input" id="city">
                    </div>
                    <div class="form-group">
                        <label class="form-label">县（区、旗）</label>
                        <input type="text" class="form-input" id="county">
                    </div>
                </div>
                
                <div class="form-row">
                    <div class="form-group">
                        <label class="form-label">行政区划代码</label>
                        <input type="text" class="form-input" id="region-code">
                    </div>
                    <div class="form-group">
                        <label class="form-label">编号</label>
                        <input type="text" class="form-input" id="certificate-id">
                    </div>
                </div>
            </div>
            
            <div class="form-section print-page">
                <h3 class="section-title">死者基本信息</h3>
                <div class="form-row">
                    <div class="form-group">
                        <label class="form-label">死者姓名</label>
                        <input type="text" class="form-input" id="deceased-name">
                    </div>
                    <div class="form-group">
                        <label class="form-label">性别</label>
                        <select class="form-select" id="gender">
                            <option value="">-- 请选择 --</option>
                            <option value="男">男</option>
                            <option value="女">女</option>
                            <option value="未知的性别">未知的性别</option>
                            <option value="未说明的性别">未说明的性别</option>
                        </select>
                    </div>
                </div>
                
                <div class="form-row">
                    <div class="form-group">
                        <label class="form-label">民族</label>
                        <input type="text" class="form-input" id="ethnicity">
                    </div>
                    <div class="form-group">
                        <label class="form-label">国家或地区</label>
                        <input type="text" class="form-input" id="country">
                    </div>
                </div>
                
                <div class="form-row">
                    <div class="form-group">
                        <label class="form-label">证件类别</label>
                        <select class="form-select" id="id-type">
                            <option value="">-- 请选择 --</option>
                            <option value="身份证">身份证</option>
                            <option value="户口簿">户口簿</option>
                            <option value="护照">护照</option>
                            <option value="军官证">军官证</option>
                            <option value="驾驶证">驾驶证</option>
                            <option value="港澳通行证">港澳通行证</option>
                            <option value="台湾通行证">台湾通行证</option>
                            <option value="其他法定有效证件">其他法定有效证件</option>
                        </select>
                    </div>
                    <div class="form-group">
                        <label class="form-label">证件号码</label>
                        <input type="text" class="form-input" id="id-number">
                    </div>
                </div>
                
                <div class="form-row">
                    <div class="form-group">
                        <label class="form-label">年龄</label>
                        <input type="text" class="form-input" id="age">
                    </div>
                    <div class="form-group">
                        <label class="form-label">婚姻状况</label>
                        <select class="form-select" id="marital-status">
                            <option value="">-- 请选择 --</option>
                            <option value="未婚">未婚</option>
                            <option value="已婚">已婚</option>
                            <option value="丧偶">丧偶</option>
                            <option value="离婚">离婚</option>
                            <option value="未说明">未说明</option>
                        </select>
                    </div>
                </div>
                
                <div class="form-row">
                    <div class="form-group">
                        <label class="form-label">出生年月日</label>
                        <input type="date" class="form-input" id="birth-date">
                    </div>
                    <div class="form-group">
                        <label class="form-label">文化程度</label>
                        <select class="form-select" id="education">
                            <option value="">-- 请选择 --</option>
                            <option value="研究生">研究生</option>
                            <option value="大学">大学</option>
                            <option value="大专">大专</option>
                            <option value="中专">中专</option>
                            <option value="技校">技校</option>
                            <option value="高中">高中</option>
                            <option value="初中及以下">初中及以下</option>
                        </select>
                    </div>
                </div>
                
                <div class="form-row">
                    <div class="form-group">
                        <label class="form-label">个人身份</label>
                        <select class="form-select" id="occupation">
                            <option value="">-- 请选择 --</option>
                            <option value="公务员">公务员</option>
                            <option value="专业技术人员">专业技术人员</option>
                            <option value="职员">职员</option>
                            <option value="企业管理者">企业管理者</option>
                            <option value="工人">工人</option>
                            <option value="农民">农民</option>
                            <option value="学生">学生</option>
                            <option value="现役军人">现役军人</option>
                            <option value="自由职业">自由职业</option>
                            <option value="个体经营者">个体经营者</option>
                            <option value="无业人员">无业人员</option>
                            <option value="离退休人员">离退休人员</option>
                            <option value="其他">其他</option>
                        </select>
                    </div>
                </div>
            </div>
            
            <div class="form-section print-page">

                <div class="form-row">
                    <div class="form-group">
                        <label class="form-label">死亡日期</label>
                        <input type="date" class="form-input" id="death-date">
                    </div>
                    <div class="form-group">
                        <label class="form-label">死亡时间（时:分）</label>
                        <input type="time" class="form-input" id="death-time">
                    </div>
                </div>
                
                <div class="form-row">
                    <div class="form-group">
                        <label class="form-label">死亡地点</label>
                        <select class="form-select" id="death-location">
                            <option value="">-- 请选择 --</option>
                            <option value="医疗卫生机构">医疗卫生机构</option>
							<option value="来院途中">来院途中</option>
                            <option value="家中">家中</option>
                            <option value="养老服务机构">养老服务机构</option>
                            <option value="其他场所">其他场所</option>
							<option value="不详">不详</option>
                        </select>
                    </div>
                    <div class="form-group">
                        <label class="form-label">死亡时是否处于妊娠期或妊娠终止后42天内</label>
                        <select class="form-select" id="pregnancy">
                            <option value="">-- 请选择 --</option>
                            <option value="是">是</option>
                            <option value="否">否</option>
                        </select>
                    </div>
                </div>
            </div>
            
            <div class="form-section print-page">
                <div class="form-row">
                    <div class="form-group-full">
                        <label class="form-label">户籍地址</label>
                        <input type="text" class="form-input" id="registered-address">
                    </div>
                </div>
                
                <div class="form-row">
                    <div class="form-group-full">
                        <label class="form-label">常住地址</label>
                        <input type="text" class="form-input" id="residential-address">
                    </div>
                </div>
                
                <div class="form-row">
                    <div class="form-group-full">
                        <label class="form-label">生前工作单位</label>
                        <input type="text" class="form-input" id="workplace">
                    </div>
                </div>
            </div>
            
            <div class="form-section print-page">
                <div class="form-row">
                    <div class="form-group">
                        <label class="form-label">可联系的家属姓名</label>
                        <input type="text" class="form-input" id="family-name">
                    </div>
                    <div class="form-group">
                        <label class="form-label">联系电话</label>
                        <input type="tel" class="form-input" id="family-phone">
                    </div>
                </div>
                
                <div class="form-row">
                    <div class="form-group-full">
                        <label class="form-label">家属住址或工作单位</label>
                        <input type="text" class="form-input" id="family-workplace">
                    </div>
                </div>
            </div>
            
            <div class="form-section print-page">
                <h3 class="section-title">致死的主要疾病诊断</h3>
                
                <!-- 三列表格布局 -->
                <table class="disease-table">
                    <thead>
                        <tr>
                            <th width="30%">致死的主要疾病诊断</th>
                            <th width="50%">疾病名称（勿填症状体征）</th>
                            <th width="20%">发病至死亡大概间隔时间</th>
                        </tr>
                    </thead>
                    <tbody>
                        <tr>
                            <td class="disease-label">I.(a) 直接死亡原因</td>
                            <td>
                                <input type="text" id="cause-a" placeholder="输入疾病名称">
                            </td>
                            <td>
                                <input type="text" id="illness-duration-a">
                            </td>
                        </tr>
                        <tr>
                            <td class="disease-label">I.(b) 引起(a)的疾病或情况</td>
                            <td>
                                <input type="text" id="cause-b">
                            </td>
                            <td>
                                <input type="text" id="illness-duration-b">
                            </td>
                        </tr>
                        <tr>
                            <td class="disease-label">I.(c) 引起(b)的疾病或情况</td>
                            <td>
                                <input type="text" id="cause-c">
                            </td>
                            <td>
                                <input type="text" id="illness-duration-c">
                            </td>
                        </tr>
                        <tr>
                            <td class="disease-label">I.(d) 引起(c)的疾病或情况</td>
                            <td>
                                <input type="text" id="cause-d">
                            </td>
                            <td>
                                <input type="text" id="illness-duration-d">
                            </td>
                        </tr>
                        <tr>
                            <td class="disease-label">II. 其他疾病诊断（促进死亡，但与导致死亡无关的其他重要情况）</td>
                            <td>
                                <input type="text" id="other-disease" placeholder="输入其他疾病名称">
                            </td>
                            <td>
                                <input type="text" id="other-duration">
                            </td>
                        </tr>
                    </tbody>
                </table>
                
                <div class="form-row" style="margin-top: 20px;">
                    <div class="form-group">
                        <label class="form-label">生前主要疾病最高诊断单位</label>
                        <select class="form-select" id="diagnosis-unit">
                            <option value="">-- 请选择 --</option>
                            <option value="三级医院">三级医院</option>
                            <option value="二级医院">二级医院</option>
                            <option value="乡镇卫生院/社区卫生服务机构">乡镇卫生院/社区卫生服务机构</option>
                            <option value="村卫生室">村卫生室</option>
                            <option value="其他医疗卫生机构">其他医疗卫生机构</option>
							<option value="末就诊">末就诊</option>
                        </select>
                    </div>
					<div class="form-group">
					    <label class="form-label">生前主要疾病最高诊断依据</label>
					    <select class="form-select" id="diagnosis-basis">
					        <option value="">-- 请选择 --</option>
					        <option value="尸检">尸检</option>
					        <option value="病理">病理</option>
							<option value="手术">手术</option>
					        <option value="临床+理化">临床+理化</option>
							<option value="临床">临床</option>
							<option value="死后推断">死后推断</option>
							<option value="不详">不详</option>
					    </select>
					</div>
                </div>
            </div>
            
            <div class="form-section print-page">
                <div class="form-row">
                    <div class="form-group">
                        <label class="form-label">医师签名</label>
                        <input type="text" class="form-input" id="doctor-signature">
                    </div>
                    <div class="form-group">
                        <label class="form-label">医疗卫生机构盖章</label>
                        <input type="text" class="form-input" id="institution" placeholder="（机构名称）">
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                </div>
                
                <div class="form-row">
                    <div class="form-group">
                        <label class="form-label">填表日期</label>
                        <input type="date" class="form-input" id="issue-date">
                    </div>
                </div>
            </div>
            
            <div class="form-section print-page">
                <h3 class="section-title">死亡调查记录（由编码人员填写）</h3>
                <div class="form-row">
                    <div class="form-group">
                        <label class="form-label">根本死亡原因</label>
                        <input type="text" class="form-input" id="root-cause">
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                    <div class="form-group">
                        <label class="form-label">ICD编码</label>
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                </div>
                
                <div class="form-row">
                    <div class="form-group-full">
                        <label class="form-label">死者生前病史及症状体症：</label>
                        <textarea class="form-input" rows="4" id="medical-history"></textarea>
                    </div>
                </div>
                
                <div class="form-row">
                    <div class="form-group">
                        <label class="form-label">被调查者姓名</label>
                        <input type="text" class="form-input" id="investigator-name">
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                    <div class="form-group">
                        <label class="form-label">与死者关系</label>
                        <input type="text" class="form-input" id="relationship">
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                </div>
                
                <div class="form-row">
                    <div class="form-group">
                        <label class="form-label">联系电话</label>
                        <input type="tel" class="form-input" id="investigator-phone">
                    </div>
                    <div class="form-group">
                        <label class="form-label">联系地址或工作单位</label>
                        <input type="text" class="form-input" id="investigator-address">
                    </div>
                </div>
                
                <div class="form-row">
                    <div class="form-group-full">
                        <label class="form-label">死因推断</label>
                        <textarea class="form-input" rows="3" id="death-inference"></textarea>
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                </div>
                
				<div class="form-row">
				    <div class="form-group">
				        <label class="form-label">调查者签名</label>
				        <input type="text" class="form-input" id="investigator-Signature">
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					<div class="form-group">
					    <label class="form-label">调查日期</label>
					    <input type="date" class="form-input" id="Signature-date">
					</div>
				</div>
				
                <div class="note-box">
                    <p><strong>注：</strong></p>
                    <p>① 此表填写范围为在家、养老服务机构。其他场所正常死亡者；</p>
                    <p>② 被调查者应为死者近亲或知情人；</p>
                    <p>③ 调查时应出具以下资料：该调查者有效身份证件，居住地派出所或村委会证明。死者身份证/或户口薄，生前病历文书。</p>
                </div>
            </div>
        </div>
        
        <div class="footer">
            <p>© 2025 医学证明管理系统 | 版本 2.1.0 | 数据更新时间: 2025-06-20</p>
        </div>
    </div>

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